Longitudinal epiphyseal bracket

Case contributed by Dr Micheál Breen

Presentation

8 year old female presents for assessment of bilateral foot deformities.

Patient Data

Age: 8 years
Gender: Female

Standing radiographs of both feet

Modality: X-ray

There is a markedly dysmorphic trapezoid morphology of the first metatarsal bilaterally, with its apex directed laterally. The medial cuneiforms are enlarged and dysmorphic in appearance with V-shaped articulations with the first metatarsals. Middle cuneiform is normal in appearance. The base of the second metatarsals are broad and overhang the middle cuneiform laterally. There is apex lateral curvature of the second metatarsals. There is secondary forefoot varus.

MRI of right foot without contrast

Modality: MRI

There is a markedly dysmorphic appearance of the first metatarsal related to the presence of a longitudinal epiphyseal bracket along its medial aspect. There is osseous fusion of the epiphysis and diaphysis distally, with open physes proximally and medially. In addition, there is an ovoid focus of calcification medial to the distal aspect of the first metatarsal. This appears separate to the bracket and in keeping with a hypoplastic metatarsal related to mild preaxial polydactyly. There is a dysmorphic, trapezoid morphology to the metatarsal, with its apex directed laterally.

The medial cuneiform is enlarged and dysmorphic in appearance with elongated medial process and a V-shaped articulation with the first metatarsal. Middle cuneiform is normal in size. The base of the second metatarsal is broad and overhangs the middle cuneiform laterally. There is apex lateral curvature of the second metatarsal.

Subjectively there is secondary forefoot varus as is expected with a longitudinal epiphyseal bracket however this would be better assessed and quantified with standing radiographs.

A small amount of marrow edema is noted at the base of the proximal phalanx of the hallux. There is no fracture line seen. This is in keeping with stress response and may be related to altered biomechanics.

The soft tissues are normal in appearance. There is no evidence of tenosynovitis. There is no joint effusion.

Case Discussion

This case is an example of longitudinal epiphyseal bracket also known as bracket epiphysis or delta phalanx. It is an uncommon growth disorder due to the presence of an anomalous secondary ossification center that extends longitudinally along the diaphysis. Although rare, longitudinal epiphyseal bracket most commonly manifests in the hands as clinodactyly and in the feet as hallux varus.

This patient was treated with bilateral resection of the "bracket epiphysis" with fat grafting to the resection bed in the first metatarsal bilaterally.

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Case Information

rID: 40598
Case created: 27th Oct 2015
Last edited: 5th Nov 2015
Inclusion in quiz mode: Included

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